Book Reviews.

Kathleen Lennon’s Explaining Human Action is a thoughtful discussion of a fundamental web of issues in the philosohy of mind and action. Though I do not think that Lennon gets to the bottom of things, what she says always shows good sense and a fine grasp of the issues and recent literature. Reading this book cannot help but stimulate thought. Suppose you lift a glass of water in order to have a drink. The movement of your arm is a physical event, so we may assume that it has physical causes. (The view that “physical changes can be completely explained by means of physical antecedents governed by laws . . . of physical science” is called “physicialism” by Lennon (p. 119). This terminology is somewhat idiosyncratic, since this view is, as stated, compatible with some forms of dualism.) These causes are, presumably, states and events in your brain and body. Call this arm movement B, and call the causally relevant inner physical states and events of your body Pi, . . . , P,,. Now, p1,..., P,, occur in a specific physical environment, one that includes, for example, the presence of the glass of water as well as a particular history of interaction with such things. Call this overall physical environment E. Given the causal relation between P,, . . , P,, and E, on the one hand, and B, on the other hand, we may suppose (taking liberties with the distinction between types and tokens) that there is a causal law along the lines of: If P,, . . . , P,, and E, then B. So far so good. But now remember that you had a reason for lifting the glass of water: you wanted (desired) to have a drink and believed that this would be a way of doing so. So we have a second explanation, one that cites your reason for so acting: you lifted the glass because of this desire and belief. This explanation cites your belief and desire both as making your action (in some respect) reusonabk and as explaining your action. Because this explanation depends crucially on the content of your belief and desire (try appealing instead to your desire to stay warm and your belief that wearing a coat is a way of doing that), Lennon calls such explanations intentional. And now the question is: how are these two explanations one physical, the other intentional related? This fundamental question an aspect of the traditional mind-body problem drives Lennon’s book. Lennon rejects eliminative materialism the view, roughly, that when we know more about the physical causes of behavior we will find commonsense intentional explanations to be otiose. Lennon sees commonsense intentional explanations as just too successful and pervasive to be given up without a fight. So we must make room for both sorts of explanation, and we must explain how they are related.

from the inflamed part; and, if the excitement thus effected becomes chronic, the glands remain enlarged, they pass to the tnberculous state, and, at length, the same degenerescence takes place, from the laws of association so remarkable between the tissues of the same structure and properties, in the glands of other parts of the body, so as to produce a diathesis analogous to the scrofulous. It has been denied that lymphatic glands, that have become swelled from sympathy, ever become tuberculous; but M. Broussais asserts, that he has witnessed it In the exterior parts of the body in the most indubitable manner : and thence it is that inflammation of the mucous membrane of the lungs is a very frequent, and indeed almost the exclusive, cause of tubercular phthisis. The same origin applies to tabes mesenterica. The signs of irritation of the stomach and bowels, which are evident throughout its ?whole duration; th? causes which determine it; the results of the examination of dead bodies ; the good effects of abstinence from food, of cooling drinks, and of revulsives, conjoin to prove, says M. Broussais, that tabes mesenterica is nothing else than irritation of the mucous membrane of the gastric canal, especially of the small intestines. (The enlarged glands, it is said in the Lectures, correspond especially to the parts of the intestine in which the inflammation had been most severe.) This irritation, which is similar to that in gastro enteritis in general, produces with more facility that enlargement of the mesenteric glands in children, because those organs are in them much developed, and enjoy a greater relative degree of vital energy than at any other period of life.
We return to the consideration of phthisis in a more particular manner.
M. Broussais has shown that this affection is the almost inevitable consequence of prolonged irritation of the mucous membrane of the lungs in lymphatic subjects; and he adduces the most powerful evidence to show that this is its almost exclusive origin. During the twelve years that he accompanied the French army through the principal countries on the continent of Europe, he had frequent occasion to witness the confirmation of the above statement, and, at the same time, of determining the influence of a cold and moist climate in its production.
When I arrived at the army in Holland, he says, 1 found phthisis so frequent there, that, whenever a catarrh, accidentally arising from cold, was prolonged in a fair, slender, and lymphatic subject, it was necessary, in a manner, to despair of his recovery. On opening those patients, the lungs were found studded with tubercles and granulations. M. Broussais then suspected that, if those patients had lived in a warmer climate, and not contracted the inflammation which marked the origin of the disease, they would not have fallen victims to phthisis; and that, if men of the same constitution, who were not yet affected with any disease, continued to be exposed to cold, they might, in contracting pulmonary inflammation, have the fate of their comrades; whilst, if they passed into a warm climate, they would escape that fatal disease. This supposition became realized: the army was transported into Italy; phthisis then became scarce, exactly in proportion to catarrh and pneumonia. Here, and afterwards in the south of Spain, tissues, from the difference in their structure, and from its longer or shorter duration. Thus, we sometimes find in the lungs, indurations, some of a white, others of a yellowish, colour, in masses more or less considerable in size, and presenting appearances more or less analogous with what is termed schirrous and tuberculous matter; in the midst of which, calculous and osseous concretions have been observed. In other subjects, there is a confused mass of black, grey, and yellowish, spots, forming so many globules, some of them hard, and others friable: the fluid they have contained has shown the same varieties of character, being sometimes purulent, sometimes sanious, at others reddish and cream-like, &c. Ulcers, and bands of cellular tissue, traversing the lungs in various directions, are other varieties of organic lesion here observed. M. Broussais has not been able to determine precisely the causes of those varieties, which have furnished nosologists with the bases for so many distinct species of the disease. Some of the more strongly-marked characters may, however, be probably referred to the following laws: 1?. Active inflammation, affecting chiefly the sanguiferous vessels, will make the carnification of the lungs prevail; but this may not be the only alteration of structure, if the organs have been long in a state of irritation.
A general disposition to irritation of the lymphatics, proved by other affections entirely of this nature, will lead to a predominant tuberculous disorganization. 3?. There will also be an affection of the same organs, happening as a consequence of irritation ofthe lymphatics of the cellular texture, which constitutes schirrus, when those irritations have existed for a long time in some external organ.
The scrofulous diathesis is, according to M. Broussais, merely the lymphatic constitution carried to the highest degree, which may be transmitted from parents to their children, just as the sanguineous and nervous temperaments may be so transferred; but scrofula cannot thence be said to be a latent disease in persons of that constitution, any more than pleurisy, or hepatitis, or other acute inflammatory affection, to which those of the sanguineous temperament are so especially liable, can be said to exist in these as constitutional diseases. This is reducing what is called the scrofulous habit to its true character.
In the treatment of scrofula, the first indication which presents itself, when the patient only shows a disposition to that malady, is to combat this disposition by hygienic measures. We cannot then act immediately on the lymphatic system to diminish its action, we must, therefore, endeavour to establish a more near equilibrium, by giving to the sanguineous system an energy which may remove the relative preponderance of the lymphatic vessels. This may be attempted by moderate exercises, especially in the open air, generous diet, wine, &c.: but, in giving tjiis impulse to the system, it will be necessary to avert carefully all causes of more especially local irritation ; the susceptibility of the stomach to excitation must be well attended to, and cold and humidity avoided. When the glands on the exterior parts of the body are tumefied, the same means may be persisted in; because this irritation very frequently arises from external causes, especially change of temperature, or from some part of the absorbent system being irritated in the manner, and with the results, described on a former occasion, (page 64). But this is not the case with the glands of the lungs and mesentery: here, according to M. Broussais, it is irritation of the mucous surfaces on which the vessels communicating with them open, which has been the origin of the affection of the glands. Here it is the inflammation of the membranous surfaces that requires our principal care, in the first instance; but, in proportion as that inflammation subsides, the treatment of the enlargement of the glands that may be suspected to remain, should approximate to the mode already indicated for scrofula, when affecting the lymphatics,of the exterior parts of the body. But this new indication, which appears only second in order in inflammatory phthisis, the causes of which are most evident, becomes primitive and fundamental in those where the phlogosis is developed only consecutively to the lymphatic disorder. The basis of the treatment, according to the former indication, should be placed on the therapeutics for catarrh, peripneumonia, and pleurisy; and, if the inflammation assumes a chronic form, it will be necessary to avoid the occasional causes, as cold and humid air, or any other irritating cause depending on the habits of life of the patient. The measures, speaking generally, are blood-letting, in the first instance, with restricted diet, and other analogous sedative measures; then revulsives ; and, at length, a recourse to means proper to balance the vitality between the sanguiferous and lymphatic systems. These measures will require modification, according to the particular forms of disease under which the irritation of the lymphatics has its origin : 1?. When pneumonia is the cause, the antiphlogistic measures should be directly debilitant. Free blood-letting will be necessary. The revulsives appropriate to it, are those which evacuate distant vessels without irritating them.
The regimen must be very restricted.
2?. The catarrhal phthisis requires a combination of antiphlogistics, sedatives, and revulsives, restricted diet in the first instance, then nourishing without being stimulant. In the first instance, the action of the sanguiferous system should be moderated by general or local 151 bleeding, according to particular circumstances; cooling drinks, and abstinence from food ; cutaneous transpiration should be favoured by the pediluvium, during the violence of the erethism; and, when this diminishes, by vesicatories and rubefacients. As soon as white and thick expectoration announces a resolution of the inflammation, tonics may be combined with emollients, the patient may be permitted to take food, and gradually return to his ordinary mode of life. When patients have previously been in a state of great exhaustion, the resolutive expectoration either does not take place, or it is too far prolonged. Thus, the chronic state appears under two forms: 1?, with dry cough, or but a little occasional spitting of transparent mucus; 2?, with abundant expectoration of thick and opaque matter. The patient's diet should here be nourishing, and wine and other tonics directed ; only observing that he eats but little towards the evening, lest some febrile exacerbation should be then induced. A weak decoction of cinchona, combined with mucilages, has appeared to M. Broussais to be the most proper medicine.
3?. Pleuritic phthisis does not, unless the patient be plethoric, require the opening of the large veins, like the pneumonic : cupping, and the application of leeches, are more appropriate, followed by the tepid bath, emollient applications over the chest, to encourage the oozing of blood after the leeches have been removed; and slightly diaphoretic drinks. Vesicatories, until there are evident signs of alleviation, M. Broussais considers, are not advisable; principally because they often lead the practitioner to suppose that the inflammation is removed, when it exists with its original violence. In many cases, he found the pain in the chest disappear on the production of a blister externally, and yet the patients have died after a few days. Dissection showed that the inflammation had persisted with its original intensity, although the pain, considered so constant a symptom of it, had been totally removed. The diet should be aqueous, or vegetable ; and the treatment indicated be continued until the most complete re-establishment of the functions: there is nothing else can attest that the inflammation of the membrane is entirely removed. From a want of due attention to this, many patients have fallen into consumption; the slight uneasiness about the chest being considered only as an indolent consequence of the previous inflammation, when it has really arisen from a less intense degree of that disorder. The utmost quiet of body, the avoiding of cold air, the use of tepid baths, and of flannel worn next the skin, with antiphlogistics adapted to the degree of the complaint, must be directed. It is this class of medicines which generally are the most efficacious against the cough that may remain ; but, when this appears to be kept up by an irritation of the mucous membrane of the larynx and bronchiae, and is not calmed by the measures indicated, the use of opium remains: " it is always the best resource against those irritations of the chest which refuse to give way to antiphlogistics, and 5?. Phthisis consequent on continued fevers, or, rather, the irritations of the lungs which succeed to those diseases, and which, by their obstinacy, lead to a fear of the formation of tubercles, requires some distinction in its treatment: 1?, if the inflammation is vehement, and the patient but little exhausted, the most rigorous antiphlogistic regimen, especially almost total abstinence from food^ although it may be urgently called for by the appetite; besides this, revulsive measures proportionate to the excitability of the subject: 2?, if the fever has produced much debility, if the inflammation be languid, obscure, or if an abundant expectoration exists, sudorifics and revulsive irritauts are ?well indicated; observing, however, that any febrile action that may remain be not augmented by them. The effects of those means should be confined to the secretory, or excretory, capillary vessels; the actions of which we wish to augment, in order to destroy the disposition which directs the fluids towards the lungs. In some cases of this kind, it has, however, been more advantageous to introduce into the stomach some astringent tonic, the effects of which are opposite to those of the foregoing agents,?such as cinchona. Morton relates instances of surprising cures effected by this bark, in obstinate coughs with hectic fever, and very abundant expectoration indicating suppuration. This success has also been obtained by many other practitioners, and by M. Broussais. The cases in which this remedy is appropriate, may be thus generalized: (a) those consequent on diseases which have produced considerable debility in a short time,?as typhous fevers, excessive haemorrhages, &c.; (&) when the patient is of a lax, feeble, lymphatic, temperament, and the stomach rather indolent; (c) in persons living in cold and humid countries, and in large populous cities, rather than in warm latitudes, exposed situations, and villages. 6?. Scorbutic phthisis, or chronic irritation of the lungs modified by the scorbutic diathesis, will require being treated according to the indications for the cure of the latter affection, which will be hereafter considered.
7?. Irritation of the lungs tending to the production of phthisis, provoked by suppressed cutaneous affections, haemorrhages, and inflammations, should generally be combatted by the antiphlogistic regimen, aided by other measures adapted to the particular indications of the individual case.
The irritation of the mucous membrane of the intestinal canal, tend, "ing to the production of tabes mesenterica, must be treated according to the principles already developed in some of the preceding articles.
The inflammations which appear in subjects affected with scrofula, are produced by the same causes, and should be treated after the same principles, as those occurring in persons in general; only bearing in mind the disposition to activity of the lymphatic vessels, and relative want of vigour of the sanguiferous system, which should lead to a more reserved use of active antiphlogistics than in persons of the opposite disposition, and to the employment of revulsives as soon as the subsidence of the more severe degree of the inflammation will permit. It 1 is an error to suppose, because tonics tend to remove the disposition to scrofula, that they arc appropriate for the treatment of irritation of the sanguiferous system which may accompany, or be consequent on, the existence of that disposition.
In a former part of this exposition (vol. xli. p. 243,) we stated that 66 when the nutritive materials are insuflicient in quantity, or are to a certain degree improper for nutrition, the animal economy falls into a state of debility, which often proceeds to actual disease;" that 6( other agents, such as cold and humid air, painful moral affections, &c. frequently debilitate the system, without producing previous irritation;" and that 66 the continued use of innutritious excitants will produce local irritation, at the same time that they influence the rest of the system in the manner just indicated." These principles point out the origin and nature of scurvy. Thus, it is observed as a consequence of the long-continued use of salted, smoked, and dried, aliments, as the principal food, whatever may be the qualities of the air, water, and other circumstances, surrounding the patients of that disease. Those materials, so ill appropriate for the alimentation of the body, although at first only leading to a decomposition of our organs from want of nutrition, do not always confine their effects to this ; they often produce an irritation of the whole lining of the alimentary canal that passes at length to inflammation and disorganization; and at length the same effects ensue in the serous membranes, in the muscles, in the articular capsules, and even in the extremities of the spongy bones. Thus, we find in the dead bodies of scorbutic patients, phlegmasia of all species, with morbid adhesions, sanguineous and serous effusions, depositions of matter and gangrene in the parenchyma of the liver and lungs; the cavities of the joints filled with fluids of different kinds, and their capsules thickened and disorganized ; the cartilages and heads of the bones carious and friable, the epiphyses separated and floating in sanious fluids; the muscles not only gorged with blood, hard, and infiltrated, but even reduced to a sort of clotted, half.putrid, mass, sometimes exactly filling their aponeurotic sheaths; sometimes the muscular layers are shrivelled, and contain pus similar to that of phlegmonous abscesses. But, in the midst of all these disorganizations, the brain and rest of the nervous system appear to be unaffected. This, as we shall presently show, will explain one very remarkable circumstance characteristic of this disease. Let us first trace the general progress of the phenomena by which it is constituted. The species of food which we stated to give rise to scurvy, fails, in the first instance, to supply to the blood the necessary quantity of nutritious materials: the muscles, which, in the healthy state of that fluid, appropriate to themselves the fibrine it contains, no longer obtaining from it the substance necessary for their action, experience the first effects in this disease. Their contractile power is gradually weakened, and is at length totally lost: thence the Iangour of the patients, the extreme fatigue they suffer from the slightest movements, and at last their absolute impossibility to move their limbs. The heart participates in this debility of the exterior muscles: it no longer pro? pels the blood with any considerable forcc through the arteries; that no. 252.
x Foreign Medical Science and Literature? fluid stagnates in its cavities, in the large veins, and successively in all parts of the body. The weakness of the heart is so great in some cases, that it becomes distended by the blood with which it is surcharged, and is found in the dead body dilated to a very considerable extent: and, even in those patients who recover, it remains particularly liable to aneurismal dilatation. Absorption is then necessarily obstructed; collections of serous fluids take place in the extremities, and in the different visceral cavities.
Thus, the first morbid effects in scurvy are of an organic nature, or, in other words, exist in the change in the properties of the solids ; but a depraved state of the fluids soon ensues; the blood loses its proper constitution, and the secretory organs, languishing in their functions, give rise to an accumulation of effete matter in the vessels, which irritates the organs with "which it is in contact, and produces at length the inflammations fa the different parts which have been pointed out. It should be remembered, too, that the subjects are liable to have inflammation excited by all the common external causes of that affection, as well as by the peculiar internal ones that have just been designated.
'6 Represent to yourself/' says M. Broussais, u the capillaries and resulting from inflammation having taken place. This explains how persons bear deprivation of food to a great extent, for a long period, without becoming affected with the phenomena characteristic of scurvy : to produce these, the aliment must possess more or less Irritating qualities; and, in proportion to the degree of excitement of the gastric organs, will be the severity of the characters of this disease.
The nature of scurvy, then, according to the doctrine of M.
Broussais, consists in, 1st. Alteration of the blood, in consequence of want of proper nutrition; 2d, irritation of the mucous membranes of the gastric organs; 3d, weakness, and at length the loss, of muscular contractility; 4th, obstruction to the circulation of the blood from debility of the heart ; 5th, irritation more or less considerable of the sanguineous capillary vessels in all the organs, extravasation of blood, destruction of different parts; and, in the midst of this extensive disorder, integrity of the texture and functions of the nervous system. The treatment of scurvy is so clearly pointed out by the foregoing theory, that it is not necessary to say much on this subject; it is the same, according to this doctrine, as that which all judicious physicians have stated to be most beneficial; fresh vegetables and acidulous fruit# in the first instance, and then a more liberal supply of nutritious food. The above doctrine, however, furnishes an indication against the use of stimulants that has sometimes been deviated from ; but always with injury when employed before the state of irritation of the stomach and small intestines has been removed. " What a lesson for the Brunonians does this disease afford, (exclaims M. Broussais,) who personify the results of our functions, and who have only two confused ideas, according to which they pretend to explain all the phenomena of the living body!" \ History of the Petechial Fever of Genoa in the years 1808 and 180$. By G. Rasori, m.d. &c. 8vo. Milan, IS 13.
From the facts related in this work another theorem may be deduced, not less important than that already proposed: it regards the inode of operation of some substances, which the author employed with so much efficacy in the treatment of the petechial fever; aud to which, in conformity to the general language, we have given the name of anti-phlogistics. Let us remember that those substances were principally tartar-emetic ; mineral kermes ; the common supertart rate of potash; and some saline purgatives and diaphoretics, as they are usually termed ; now, we may reduce to two the opinions which, in 1800, were most generally prevalent amongst physicians respecting the medicinal qualities of those saline substances. One was the opinion of the followers of Brown, and that most generally adopted. The Brunonians considered those we have mentioned in the aspect of stimulants ; and, amongst the most active of stimulants, they placed the kermes j and they attributed so much efficacy to it, that, fortunately, they did not hesitate to employ it even in that peripncu,.
?ionyf which thpy chose to term asthenic: they also considered the X 3 tartar-emetic, and other substances above enumerated, as incitants i that is, if they did not, as frequently happened by means of the immoderate evacuation they produced, become indirect sedatives, or rather debilitants. So, whenever subtraction of the fluids from the body did not arise from their action, their effects were considered as stimulant; and, by this happy error, those medicines sometimes were employed with success in certain pretended asthenic diseases. On the contrary, those entertaining the more ancient notion, never acknowledged their general properties, which Brown first investigated with a philosophical spirit, and discovered through so many varied forms in different medicines; they did not consider these substances ?with the view to discern whether they principally augmented or lessened the vital power, or as they have since been more philosophically regarded, whether they produce excitement, or an opposite state. It was the last and particular, or in a manner local, effect tjiat might be expected from them which they solely took into consideration. Thus, they saw in the kermes an jexpectorant or an incisive; in tartarized antimony, an emetic or a sudorific; in tho cremor tartar, a purgative or a diuretic: and all at the best agreed in classing, in a general manner, some of the remedies of that kind under the common denomination of anti-plilogistics ; meaning to say that the various crises, effected by their means, tended to destroy the phlogosis or state of over-excitement; and it should be remarked, that those good old practitioners relied so firmly on the idea of the especial production of this crisis or evacuation, that none of them believed the substances designated ever acted in a beneficial manner, unless some critical evacuation of the peccant humors, or of saburrte, or of the morbid femes, followed their use.
Such were the opinions of the medical world, new and ancient, when the fortunate experience of Rasori, in the epidemy of Genoa, came to open the eyes of physicians. 1st. Many of the patients were treated with those substances.
2d. They were administered in such closes, that, if the remedy were appropriate, they were sufficient to prove beneficial; whilst, if they had been inappropriate and contraindicated, they could not fail being injurious. 3d. Their sensible and ultimate effects were the permanent cure of the disease; which necessarily indicates an appropriate method of treatment. 4th. The use of those sikbstances was, in some cases, accompanied with proportionate evacuations. But, 5th, in a much greater number of cases, no evacuation was manifest, or not manifest in a degree at all appropriate to either the intensity of the disease, the degree of amendment, or the extent of the dose : thus, the most remarkable phenomenon, observed from the action of those remedies, was the restitution of health; and their evacuating effects, generally speaking, were less in proportion to the greater intensity of the disease. Let us then reason dispassionately on those data, relinquishing all prejudice and favourite maxims, to listen to, and profit by, the useful lessons they furnish.
We then thus address the disciples of Brown; ? In what way will you explain the operation of the tartar-emetic, kermes, nitre, and pupertrate of potash, in those eases; and the mode in which they effected the cure ? By stimulating ? That is not possible. Reconsider the numerous arguments by which it has been shown that the fever of Genoa, even in the period called nervous, preserved its in. flammatory diathesis. Can it be said that an inflammatory disease may be cured by stimulants? Consider that when these substances were beneficial, opium, wine, and the true stimulants, were manifestly deleterious.
Is not that an argument that the one operated in a manner contrary to the other ? Reflect that the same salutary effects which were obtained from the tartarized antimony, and other saline substances, were also obtained from general blood-letting, and from scarification, which certainly are sedative. Do not similar effects forcibly indicate a similarity of causes ? But, do you require an argument that cannot be replied to ? The medicines above alluded to, in many cases, produced an easy, decisive, and rapid cure: in others they produced the best effects, in too great a number of cases to permit their success to be attributed to hazard, or proportionate evacuation, after the occurrence of which you are ready to acknowledge that tfoe stimulant, action is very far inferior to the debility induced by the subtraction of the fluids. They then cured, although ihey so much debilitated ? Then they cured, because they debilitated. Can it in reality be believed that, unless that were the case, the return of health would have been effected, in such a state of disease, in a manner so manifestly connected with the use of those remedies, so rapidly and so undisturbed by any sinister accident.
You are then necessarily led to admit, that the re-establishment of health, in the former cases produced by a stimulant action, was in the latter produced by an opposite mode of action : but will you now say, that if those remedies manifested a debilitant curative action, that it was indirect debility, resulting as a consequence of the evacuation they produced, without which their action would have been purely stimulant?
It will be easy to show the erroneousness of your reasoning. Although it has been allowed that proportionate evacuations were not wanting in many cases, yet such evacuations were by no means present to such an extent as was expected in a much greater number of others, which, except in this respect, were identical with the former. There were the same nervous characters present in these as in the former. In both, the use of opium, ether, and alcohol, was so manifestly and promptly injurious as not to be at all equivocal.
On the contrary, the remedies that were beneficial in the one, were equally so in the other, arfd in the same stage of the disease. Those remedies also showed themselves equally salutary, whether they dicf or did not produce evacuations: independently of the presence or absence of these their effects were directly opposite to those resulting; from substances decisively stimulant. The only consequence to which we are led, then, is this: the tartar-emetic, and other saline substances above enumerated, directly diminish excitement, although no evacuactions are produced.
You are wrong, then, Brunonians! in asserting that all medicines stis mulate: there are some which manifest a contrary action to that of sti9 {uuJautS; immediately and without any abstraction of fluids. There are then contra-stimulant powers; and this is the second grand truth "which Rasori has the merit of having developed. In the work on the epidemy of Genoa we only find the first foundation of this truth. We shall hereafter have to notice some further arguments by which it is rendered more evident. Those already advanced have peremptorily established it; and many have not been noticed that might have been adduced. We might, for example, show that the small quantity of water or of gastric fluid evacuated from the stomach by the action of tartar-emetic, does not bear any relation in degree to the great faintness and weakness which it often produces. We might add to this, that the antiphlogistic effects of the nitre were too considerable to be attributed to the small increase of the quantity of urine or of sweat ?which it produced. To these and some other similar arguments we shall return at a future period. Here we terminate our dispute with the disciples of the physician of Edinburgh : the followers of the more ancient school will now engage a little of our attention.
The greater part of these certainly insisted much on the importance of attending to the symptoms of diseases ; but they never raised their views of the nature of remedies to their general stimulant or contrastimulant qualities: thus, they would pretend, that, if cremor tartar, tartarized antimony, nitre, and mineral kermes, were beneficial in the petechial fever just described, and in many other analogous disorders, they were beneficial only in this manner; that the one, for example, would act as an incisive and resolvant of the ill.concocted matter which, being thrown on the lungs, had oppressed them ; that the other would dissipate the saburres of the stomach and intestines, either by stool or vomiting; the third would relieve by the urinary passages, or by the pores of the skin, the sanguineous system of the morbid matter, when in the torrent of the circulation it is transported into their circle.
?But there need no other means for the destruction of this venerable system, than the clear evidence of facts. No doctrine is more effica. ciously combatted by the simple history of the epidemy of Genoa, than the doctrine of the symptomatic physicians. What rules were observed, then, by Rasori? It seems that he took, as it were, a pleasure in applying those remedies in a sense expressly contrary to those maxims, being secure of his favourable success. Would he, in con* fortuity to the indications of the symptoms, when he saw subsultus of the tendons, lethargic stupor, and placid delirium, have resorted to tartarized antimony, and not rather to musk and the anodyne liquor? Would he have had recourse to purgatives, or to emetics, in the advanced stage of the disease,?in the malignant period, when there was no metcorism, nor indications of gastric disorder, present? Would he have used kermes, when the chest was free ? or nitre, when the urine was copious? Would he have terminated the cure with emetics, diuretics, purgatives, leeches, and scarifications, without sinapisms, without blisters, without serpentaria, without ammonia? Would he have administered ice, when there was danger of phlogistic re-action ? And, above all, would he have placed the least confidence in saline lacdLcines and in tartar emctic, without producing any evacuations by i ? 2 Rasori, on the Petechial Fever of Genoa, 15$ faeces, vomiting, copious flow of urine, or profuse sweating, according to the pathognomonic indications of the materia morbosa ? llasori, then, treated the disease in a very different manner than from the indications of the symptoms. He entirely neglected ail those that are commonly considered as the most dangerous; and, even though the remedies he adopted might, according to the old doctrine, be theoretically reduced to symptomatic medicine; in the greater number of particular cases where he adopted those remedies, they were either contra-indicated according to that doctrine, or they should not have been beneficial, because they did not produce the effects that were expected from them.
But, if Rasori did not treat the symptoms, and nevertheless produced a restoration of health ; if his remedies were not conformable to the indications of the symptoms in themselves; on what principles, then, did his remedies act? Not as emetics, diuretics, and cathartics; because they were so frequently beneficial without producing vomiting, diuresis, or catharsis. Not as anliphlogistics, in the old sense of that term; since they were beneficial in many cases where no evacuations were produced, (even when there did not exist the characteristics of clearly and well-marked inflammation",) and where no sensible crisis ensued.
How, then, we repeat, were those remedies beneficial?
Disciples of the various schools anterior to Brownism I you cannot refuse to admit that those substances possess other qualities than those of purgatives, emetics, and sudorifics; without the exertion of which we have seen them effect the restoration of health : you must allow them other qualities than the incisive, the attenuant, the eliminatory of the morbid matter, &c. since we have been shown such an hypothesis to have been inadmissible in a great number of cases : you must admit in them a third general quality, to which a too unimportant, and merely secondary, character has been attributed; we mean a refrigerant, antiphlogistic one, or, in other words, a sedative of excitement. You must perceive that those remedies, or those principles in general, had an effect directly opposite to that either of wine, of opium, of ether, or of alcohol; and you so well discern it, that you fear to employ them to a considerable extent where there exists great real or apparent debility. You, then, confess that they destroy phlogosis where it exists ; and moderate vital excitement, already, as we say, carried to an inordinate extent. In this respect you are in the right; but you must not too far subtilize your reasonings on this point, and attribute the effects above designated to the evacuations they produce. Experience in the petechial fever of Genoa, supported on other occasions, has demonstrated, and in such a manner as not to admit of reply, (by facts), that those effects were produced without any evacuations.
If we then isolate from what is proved all those circumstances which are not constant and well.ascertained, and which it is useless to enter into the consideration of, we shall then feel assured that the remedies in question must have produced their effects on different principles from those which you assume. In the fever of Genoa, the medicines used certainly could not operate by stimulating, since they caused no evacuations: they did not operate by an elective faculty, or 160 Foreign Medical Science and Literature. as cathartics, emetics, expectorants, diuretics, or diaphoretics: they did not act by dissolving or attenuating lentor of the fluids, or by producing decomposition of the morbid matter. We then first learned, from observation worthy of the age in which we exist, that they produced their beneficial effects by an agency directly opposite to that of a stimulus. There exist, then, medicinal substances, which, contrary to the doctrine of Brown, cause sedative effects independently of any subtraction, and therefore what may be properly termed contra-stimulant agents, as it has been thought proper to term them, (we will not now dispute on the propriety of names ;) and this we consider to be one of the greatest of the many truths disclosed in the work of Rasori, and one which we shall find to have been confirmed by along series of subsequent observations. The existence of sedalive substances was long since known j but the sedatives of the ancients are not the contra-stimulants of Rasori.
Opium was a sedative with them,?if not castor ! They not only considered as sedatives those substances which immediately diminished action, but those also which depressed excitement by first causing inordinate action. Opiates and sulphate of soda were used at the same time as sedatives. They looked to the ultimate effects without considering how they were produced, and were thus constrained to arrange/ under the same class all the remedies of the materia medica, since all of them are in some cases sedatives on their principles ; and thus to comprise, under the same title, substances of the most opposite nature.
Antiphlogistics were also known in former times; but the antiphlogistics of the ancients present too circumscribed, and indeed false, an idea of the remedies which solely oppose phlogosis; and the contrastimulants of Rasori are more than the antiphlogistics: they combat, in general, all states of excitement at all accompanied with the inflammatory process. Besides, the antiphlogistics of the ancients were only those acid, or sub-acid, mineral, saline, substances which refrigerate the palate; whilst there are many contra-stimulants* according to Rasori, that do not produce that effect.
The Brunonians had their sedatives; but the sedatives of the Brunonians, besides being thought to act thus always by means of subtraction, or as negative stimulants, presented to them another erroneous idea; since they gave rise to an idea of principles, which induced, by means of their action, a state of debility or of lessened excitement. When it has happened, then, that a disease of an inflammatory nature has been accompanied by tl*e phenomena of depressed excitement, as was the case in the fever of Genoa, the use of those sedatives, as they are termed, has not unfrequently realized their ideas: depressed excitement being evinced by the occurrence of death. It is not, then, a renewal of an old maxim, but the discovery of a new truth, or, at least, the rectification of some erroneous views of the ancients, that we owe to the Clinical School of Milan. The ancients had no knowledge of the pupillary membrane,?of that membrane which completely fills up the opening in the iris termed the pupil. Riolan clearly showed, towards the end of the fifteenth century, that infants do not see at the time of birth ;+ but he did not attribute the cause to the existence of the pupillary membrane, of which he does not speak. Littre also stated, at the Academy of Sciences, in 1707* that blindness at the time of birth was produced by a membrane which obliterated the pupil; but he did not give any description of it. It appears that this anatomist considered this membraue as an extraordinary or morbid formation.
Wachendorf, a German physician, is the first that made it known through the medium of the press, in 1740.J Two years after, Haller, who was not acquainted with the dissertation of Wachen* dorf, gave a more exact description of it, with a figure,? believing himself to be the first who had observed this membrane; but he Foreign Medical Scienci and Literature. under consideration, but indicated, also, the mode in, which it might "foe cleArly seen and demonstrated.* \ ' ?' fv,*v'> m A Other celebrated anatomists, amongst whom wcsre) HurfTBB and Blumenbagh, also recognized and demonstrated the -pupillary membrane: Wrisberg,.especially, has given a v^r^ de,tai|ed description,of in his Commentationcs Mpdicce.i The pupillary membrane is not ordinarily found in infants \yho have] Kved for a short tiuje after birth, which has led me to beljeve, after CjATaker, a celebrated German anatomist, and ilaller? tha^ this njeiftbrane, if it has not already been ruptured by causes which a,pe. up-|nown to us^ (which do.^s sometirpes {lapp^n, because it cannot always be found,) is broken duripg, or a short time after, the birth, either bjrr gin of the pupillary foramen, that the cellular tissue is derived which gives rise to the pupillary membrane.
Let me add to this account of the pupillary membrane, the existence of which may prevent infants seeing at the time of birth, that I am equally persuaded that they do not hear on coming into the world, any more than see, and even that such is the case more generally. I form this opinion from the circumstances which I am about to detail. It is certain that there are many cases of deafness which may arise from the cavity of the tympanum being full of mucous or other humours.
The results of anatomical and pathological observation hare so frequently proved it, that we cannot doubt of the existence of this species of deafness. Now, as in the foetus, the cavity of the tympanum is always full of mucous matter, as well as the Eustachian tube, of "which I have been several times convinced by an attentive examination of the internal parts of the car, 1 do not doubt that this abundant existence of mucus may essentially cause deafness, which may continue as long as the cavities above designated remain full of it. It appears that it is only when the foetus has respired, and that the pituitary membrane has become freed from the mucous matters with which it is covered, and which fills the nasal cavities, as well as the Eustachian tubes and the tympanal cavities, that infants begin to hear.
Indeed, when we examine the ears of those who have lived a few hours, we find them no longer equally filled with the mucous matters: this I have several times ascertained. 1 have no doubt but that children remain deaf and dumb from their birth from this cause, if it be permanent or because the cavity of the tympanum remains incommoded by some other matter. At other times there exists a want of the development of the auricular cavities,?an organic vice which 1 have found in one ease of primeval deafness. Dr. Laefmec on Mediate Auscultation* 165 fcVot)fe<) fty Avenbruggeu ; but so far superior to them, that It furnishes, for the most part, 44 novel, sure, and striking signs, easily to be discerned, and calculated to render the diagnosis of almost all the diseases of the lungs, the pleura, and the htart, more certain, and perhaps more circumstantiate, than surgical diagnostics established by the Aid of the sound or the touch of the finger?" A wooden cylinder, a foot long, from eighteen to twenty lines in diameter, divisible in the middle of its length by a screw, (to render it conveniently portable.) pierced in the centre by a tube nine lines in circumference; but terminating at one en<l by a tunnel.like cavity, about an inch and a half in longitudinal dimension, and of nearty an equal extent in diameter at its large extremity, with a sort of plug, itself pierced in the middle by a canal three lines in diameter, to be occasionally inserted into this tunnel, by which it is rendered a simple cylinder,?is the instrument used by M. Laenncc, and to which he has applied the term stethoscope.
Here we stop in our description, to have a little personal converse with the reader, in order to remove the prejudicial and incorrect sentiments he will probably form respecting the present subject of our labours. Two large volumes devoted to the diagnosis of the diseases of the thoracic organs, and by meatis of the signs perceived by one of the senses only, by the aid of an instrument too, in which, without a jaundiced eye, a little charlatanism might be suspected, are certainly not good auspices. We ourselves formed similar ideas; but we had not perused many pages of the work before we began to blame the sf<uthor for having given to it the title it bears; and, on proceeding n little further, we felt disposed to censure the method he has chosen of making the principal object of his work the designation of the advantage that may be dtrived from the use of the cylinder in distinguishing the different lesions of the lungs, and rendering every thing else subordinate to this design: the facts in pathological anatomy, even Although occupying a greater extent of sjxice, bting inserted merely its accessories. We regard these facts, many of which are novel and of the most interesting kind, as forming a part of the work certainly not inferior in importance to the new means of diagnosis; although we are not one of those to whom a passage in the dedication* is, in this case at least, applicable: Nostra enim <etas incuriosa quoyue suorum; et m quid novi ab homine coevo in medio ponitur, risu ut plurimum ineptisque cat Hint ionibus excipiunt: qmppe facilius est aspernari quam experiri.
Besides the novel pathological observations above alluded to, this "work contains extensive judicial remarks on the value of the signs of the diseases of the thoracic organs; and some important indications for their cure, especially for that of phthisis. This part constitutes an excellent specimen of the results Of the philosophic spirit with which pathology is studied in France at the present period. We know not how to speak more forcibly in its praise.
YVe shall, then, take a somewhat different course from that which * To tlie College of Physicians of Paris.
tifj FoPeigrC Medical *fyiirtte and ZM<ir(Uurt\ Laetmfcti hfcs doa6 in the exposition we are about to give of the con* tents of his work.
Pathology shall engage our first and chief atten-j tion ? and we shall treat of the new means of diagnosis in a secondary way, as it is treated of in medical writings in general; taking ear?} however, to omit nothing of considerable importance respecting it. ?, In order to open as clear a view as possible before the reader, and* to favotir conciseness of narration in our progress^ we shall commence with a general account of the phenomena developed by the stethoscope in the state of health especially, and of the mode of exploring them#, Those phenomena relate to the voice, respiration, rattles^* and tha action oj the htart. The instrument should be held as a pen is done^ a^nd applied to the chest steadily and firmly, with the hand near to it^> so as to secure its proper application* The end of the cylinder, in which is the tunnel-like cavity* is to be in contact with the patient^ and the orifice of the ear of the physician gently pressed against the> opposite extremity. When the voice and the movements of the heart; are exploded, the perforated plfig is to be inserted. Jn extremely meagre persons, the surface of whose chest presents grooves betwfcenr the ridges of the muscles and bones, some cotlon covered by a piece of cloth; or a piece of soft paper folded, should be placed beneath the end of the stethoscope. This will often be requisite on the stertfHrft* We freed not treat of the manner, and peculiar force/ with which sound is conveyed through long rods of hard and dry woody and simftfc* tubes: these things arc well known by every person the leastac.? QUfflntcd wkh the science of phjrsies*